MEDICAL PROVIDERS AND COMMUNITY AGENCIES

Transcription

1 MEDICAL PROVIDERS AND COMMUNITY AGENCIES A GERIATRICIAN AND A COMMUNITY FAMILY CAREGIVER SPECIALIST MAKE THE CASE FOR CONSISTENT AND COORDINATED DEMENTIA CARE

2 ANN O'SULLIVAN, OTR/L, LSW, FAOTA SOUTHERN MAINE AGENCY ON AGING ROGER RENFREW, MD, FACP REDINGTON MEDICAL PRIMARY CARE

3 DISCLOSURE ROGER RENFREW AND ANN O SULLIVAN HAVE NOTHING TO DISCLOSE WITH REGARD TO COMMERCIAL RELATIONSHIPS

4 OUTLINE PROBLEM STATEMENT: ANN PRACTICE MODELS: ROGER CONNECTING WITH COMMUNITY RESOURCES: ANN COMMUNICATION: ROGER AND ANN

5 PROBLEM STATEMENT

6 THE BASICS MAINE IS THE OLDEST STATE MAINE HAS HIGH PERCENTAGE OF PEOPLE OVER THE AGE OF 65 AGE IS A RISK FACTOR FOR DEMENTIA QUALITY CARE FOR PEOPLE WITH DEMENTIA IS A CHALLENGE

7 PEOPLE WITH DEMENTIA AND CAREGIVERS 70% RECEIVE CARE FROM FAMILY AND FRIENDS 25,000 PEOPLE WITH DEMENTIA IN MAINE 40% INCREASE EXPECTED BY ,000 CAREGIVERS 77,000,000 HOURS OF UNPAID CARE ALZHEIMER S ASSOCIATION, 2014

8 WHAT DO FAMILY CAREGIVERS PROVIDE? ADL / IADL ASSISTANCE MANAGEMENT OF SAFETY BEHAVIOR SYMPTOM MANAGEMENT IDENTIFICATION AND COORDINATION OF SUPPORTIVE SERVICES FACILITATION OF HEALTHCARE VISITS ADVOCACY DECISION-MAKING SUPPORT

9 UNMET NEEDS UNMET DEMENTIA-RELATED NEEDS GROUPS WITH HIGHER NEEDS MULTI-DIMENSIONAL INCREASED RISK OF NEGATIVE HEALTH OUTCOMES JAGS 61: , 2013

10 UNMET NEEDS OF PEOPLE WITH DEMENTIA EVALUATION AND DIAGNOSIS OF DEMENTIA GENERAL HEALTH AND MEDICAL CARE MEANINGFUL ACTIVITIES LEGAL ISSUES AND ADVANCE CARE PLANNING PERSONAL AND HOME SAFETY JAGS 61: , 2013

11 UNMET NEEDS OF FAMILY CAREGIVERS PWD AND CAREGIVER SAFETY RESOURCE REFERRALS CAREGIVER EDUCATION MENTAL HEALTH CARE JAGS 61: , 2013

12 CARE PLANS GOALS OF CARE COMPREHENSIVE INDIVIDUALIZED COORDINATED PWD AND CAREGIVER AS TEAM MEMBERS MONITORED AND REVISED AS NEEDED

13 CARE PLAN CONCERNS CARE PLANS OFTEN LACK SUPPORT GROUPS MANAGEMENT OF WANDERING RISK CAREGIVER TRAINING MEDICATION ADJUSTMENT JAGS 61: , 2013

14 WHAT IS NEEDED HEALTH CARE FOR PERSONS WITH DEMENTIA IS INCONSISTENT OFTEN SUBOPTIMAL LARGELY UNPLANNED PARTNERSHIP WITH CAREGIVERS IN INTEGRAL TO IMPROVING CARE WELLBEING AND BEHAVIORAL STABILITY OF PERSONS WITH DEMENTIA ARE STRONGLY INFLUENCED BY THE WELLBEING OF THEIR CAREGIVERS AAN, 2013

15 DEMENTIA MANAGEMENT QUALITY MEASURES MEASURES TO EVALUATE AND TRACK DEMENTIA CARE ALL STAGES IN A SINGLE MEASURE SET USE FUNCTIONAL STAGING TO PLAN CARE USE VALIDATED ASSESSMENT AND INTERVENTION STRATEGIES REASSESS AND UPDATE AAN, 2013

16 (IN)COORDINATED DEMENTIA CARE: COMMENTS FROM A PRETTY SAVVY GROUP WE WERE GIVEN NO GUIDANCE FROM THE MEDICAL COMMUNITY ON COMMUNITY RESOURCES. MY MOTHER IN LAW WAS GIVEN MEMORY MEDS AND SENT HOME. THE FAMILY DOCTOR WAS A TOTAL HERO AND HELPED TO GET MOM THROUGH VERY ROUGH TRANSITIONS WHEN SYSTEMS WERE NOT WORKING.

17 MORE COMMENTS. I THINK IF THE MEDICAL COMMUNITY COULD DO WARM HAND OFFS TO THE COMMUNITY RESOURCES, THAT WOULD BE HELPFUL WITH SOME WAY FOR THE AGENCY TO PROVIDE THE PHYSICIAN S OFFICE WITH AN OUTCOME.SUPPORT GROUP, HOME BASED CARE, ETC THE SYSTEM NEEDS TO BE MORE CONSISTENT IN SERVICE PROVISION AND THE UNDERSTANDING OF THE CAREGIVERS NEEDS AND DEPTH OF FEELINGS INVOLVED IN DECISION MAKING.

18 PRACTICE MODELS

19 AGS INITIATIVE 3 OR MORE (3+) INTRODUCED AT AGS MEETING MAY 2012 OVER 50% OF OLDER ADULTS HAVE 3 OR MORE CHRONIC CONDITIONS VA STUDY: FOR THE 15 MOST COMMON TRIPLETS OF CONDITIONS 7-9 CONDITIONS ALMOST ALL EXISTING GUIDELINES HAVE SINGLE DISEASE FOCUS INITIATIVE IS TO DEVELOP GUIDING PRINCIPLES FOR THE MANAGEMENT OF THE OLDER ADULT WITH COMORBID CONDITIONS. AGS EXPERT PANEL, J AM GERIAT SOC 60: , 2012

20 CHRONIC DISEASE MANAGEMENT IN THE ELDERLY MULTIPLE MEDICAL CONDITIONS MULTIPLE QUALITY INDICATORS LITTLE RESEARCH ON THESE METRICS IN VULNERABLE ELDERLY OR THOSE WITH MULTIPLE COMORBIDITIES HAVE SIGNIFICANT FUNCTIONAL IMPACTS

21 GERIATRIC SYNDROMES COMMON SYNDROMES IN ELDER PERSONS IMPAIR FUNCTION INCREASE CAREGIVER STRESS INCREASE RISK OF INSTITUTIONALIZATION ARE UNDER-TREATED OFTEN TRAVEL IN TANDEM

22 GERIATRIC SYNDROMES MEMORY IMPAIRMENT FALLS AND GAIT IMPAIRMENT URINARY INCONTINENCE DELIRIUM SLEEP PROBLEMS POLYPHARMACY ELDER MISTREATMENT FRAILTY

23 PROVIDER CHALLENGE MANAGE CHRONIC ILLNESSES LOOK FOR AND EVALUATE GERIATRIC SYNDROMES ADDRESS OFTEN COMPLEX SOCIAL ISSUES

24 CHALLENGE NEED A STRUCTURED APPROACH AND A TEAM

25 ACOVE ASSESSING CARE OF THE VULNERABLE ELDERLY WENGER ET AL. J AM GERIAT SOC 55:S247-S252,2007

26 ACOVE SERIES OF QUALITY INDICATORS DEVELOPED BY THE AGS, ACP, UCLA + THE RAND CORPORATION DIRECTED AT THE VULNERABLE ELDERLY SUBSET OF THE ELDERLY POPULATION

27 MODELS TO UTILIZE A STRUCTURED APPROACH PHYSICIAN WITH NP OR PA AS A TEAM PCMH SIMILAR TO ABOVE BUILT ON BROADER TEAM STRUCTURE PCS USING SEVERAL STRUCTURED VISITS

28 PHYSICIAN WITH NP OR PA AS A TEAM OUR MODEL

29 ACOVE FOR DEMENTIA 17 INDICATORS FOR DEMENTIA USED TO DEVELOP A CHECKLIST AND TEMPLATES WENGER ET AL. J AM GERIAT SOC 55:S247-S252, 2007

30 OUR PRACTICE CHECKLIST BASED ON ACOVE DRIVES TEMPLATES IN EMR SCREENING DIAGNOSIS MANAGEMENT FOLLOW UP

31 HOW WE SCREEN CASE FINDING TEAM ANY ONE ON MY OFFICE TEAM CAREGIVER INFORMANT INTERVIEW CONCERNED OTHERS SCREEN OTHERWISE ASYMPTOMATIC AWV ALL > 75 (PREVALENCE 11% Y/O) MEDICAL RECORDS (REMINDERS) FALLS

32 SPECIFIC VISITS WITH PA BASIC HISTORY (BASED ON TEMPLATE) MMSE/MOCA DEPRESSION SCREEN PE + NEURO EXAM BASIC W/U IMAGING FUNCTIONAL EVALUATION MEDICATION REVIEW OTHER MEDICAL ILLNESSES

33 MANAGEMENT SPECIFIC VISITS WITH PA MUCH MORE THAN MEDICATION MEDICAL ILLNESSES GOAL IS FUNCTION PATIENT AND CAREGIVER RESOURCES CONNECT TO COMMUNITY RESOURCES LEGAL ISSUES CAPACITY DRIVING

34 MANAGEMENT MEDICATION MEDICATIONS FOR DEMENTIA AND BEHAVIORAL DISTURBANCE IF BEHAVIORAL INTERVENTIONS FAIL AND RISKS ACCEPTED POLYPHARMACY

35 OFFICE TEAM SECRETARY MEDICAL RECORDS MA PHYSICIAN PA

36 REALITY CHECK VULNERABLE ELDERS SPEND % OF THEIR TIME IN THE OFFICE OF A PHYSICIAN OR OTHER PROVIDER

37 REALITY CHECK VULNERABLE ELDERS SPEND <0.1% (1/1000) OF THEIR TIME IN THE OFFICE OF A PHYSICIAN OR OTHER PROVIDER

38 TEAM IN GERIATRICS Community resources Support system Office Team

39 TEAM THE TEAM WE NEED EXTENDS WELL BEYOND THE CLINICIAN S OFFICE. ONLY A SMALL AMOUNT OF THE CARE OF A MEMORY IMPAIRED OLDER ADULT OCCURS IN THE OFFICE. THE OFFICE DOES NOT PLAY THE MOST IMPORTANT ROLE IN THE INDIVIDUAL S CARE. HOW TO CONNECT TO THAT BROADER TEAM?

40 Q/I EARLY RECOGNITION ON REVIEWING ACOVE INDICATORS THAT WE WERE NOT ROUTINELY CONNECTING WITH COMMUNITY RESOURCES ESTABLISHED WORKING RELATIONSHIP WITH OUR AAA FOLDER OF MATERIALS NIA BOOKLET ON DEMENTIA ENCOURAGE CONNECTION

41 TEAM IN GERIATRICS Community resources Support system Office Team

42 TEAM IN GERIATRICS HOW DO WE WORK BEST AS A TEAM? HOW DO WE COMMUNICATE?

43 CONNECTING WITH COMMUNITY RESOURCES

44 WHAT DIFFERENCE CAN COMMUNITY CONNECTIONS MAKE? ASSISTANCE WITH NAVIGATING A COMPLEX SYSTEM REDUCTION OF CAREGIVER STRESS

45 WHAT TYPES OF HELP ARE AVAILABLE? INFORMATION RESOURCES FINANCIAL ASSISTANCE NUTRITION ACTIVITY SUPPORT EDUCATION GUIDANCE RESPITE

46 HOW DO YOU FIND RESOURCES? OAR TOOLKIT AGENCIES ON AGING / ADRC

47 OAR TOOLKIT INITIALLY DEVELOPED UNDER SMAA MINI-GRANT TO UNE GEC WIDELY DISSEMINATED TO PROVIDERS IN YORK AND CUMBERLAND COUNTIES UPDATED DOWNLOADABLE VERSION, 2009 NEW UPDATE 2014 AVAILABLE AT AND

48 SINGLE ENTRY POINT / NO WRONG DOOR MEDCAPS AGENCIES ON AGING / AGING AND DISABILITY RESOURCE CENTERS (ADRC)

49 AGENCIES ON AGING / ADRC PROBLEM SOLVING RESOURCE IDENTIFICATION AND ACCESS HEALTH INSURANCE COUNSELING NUTRITION PROGRAMS HEALTHY AGING PROGRAMS VOLUNTEER OPPORTUNITIES FAMILY CAREGIVER SUPPORT

50 FAMILY CAREGIVER SUPPORT PROGRAM EDUCATION SAVVY CAREGIVER COUNSELING & SUPPORT ONE ON ONE / GROUP HELP WITH PROBLEM SOLVING AROUND CAREGIVING RESPITE

51 COMMUNITY LINKS - SMAA WEB-BASED FORM WITH CHECK BOXES AND NARRATIVE CLIENT / CAREGIVER RELEASE OF INFORMATION SPECIFY FOLLOW-UP INSTANT CONFIRMATION OF RECEIPT

52 STATEWIDE AAA REFERRALS SOUTHERN MAINE AGENCY ON AGING SENIORS PLUS -LINKS-REFERRAL/ SPECTRUM GENERATIONS LINKS.SPECGEN.ORG EASTERN AGENCY ON AGING AGENCY-ON-AGING-REFERRAL-FORM/

53 COMMUNICATION

54 COMMUNICATION THE MEANINGFUL EXCHANGE OF INFORMATION BETWEEN TWO OR MORE LIVING CREATURES

55 TEAM IN GERIATRICS Community resources Support system Office Team

56 CARE PLAN BUSY PHYSICIANS, INCLUDING GERIATRICIANS, HAVE NEITHER THE TIME NOR, IN SOME CASES, THE SKILLS TO ADEQUATELY MANAGE MANY ASPECTS OF DEMENTIA, INCLUDING COORDINATING SOCIAL AND MEDICAL CARE, INSTRUCTING CAREGIVERS, AND COUNSELING FAMILIES. JAGS 61: , 2013

57 COMMUNICATION I THINK IF THE MEDICAL COMMUNITY COULD DO WARM HAND-OFFS TO THE COMMUNITY RESOURCES, THAT WOULD BE HELPFUL WITH SOME WAY FOR THE AGENCY TO PROVIDE THE PHYSICIAN S OFFICE WITH AN OUTCOME.SUPPORT GROUP, HOME BASED CARE, ETC

58 COMMUNICATION RIGHT NOW, DEPENDS ON THE PROVIDER ENCOURAGING THE PWD OR CAREGIVER TO ACCESS THE SERVICES. REFERRAL CAN BE MADE THROUGH COMMUNITY LINKS AT AAA FEEDBACK OPPORTUNITY

59 CARE PLAN DEVELOPMENT OF AN INDIVIDUALIZED CARE PLAN HAS DEMONSTRATED SIGNIFICANT GAPS WHICH THE CARE PLAN CAN ADDRESS. NOTE THESE GAPS CAN BE ADDRESSED BY A STRUCTURED AND TEMPLATE APPROACH FURTHER STUDY WILL TEST CHANGES IN OUTCOMES JAGS 61: , 2013

60 CONTINUING THE CONVERSATION

61 THANK YOU

62 CONTACT INFORMATION ROGER RENFREW ANN O SULLIVAN AOSULLIVAN@SMAAA.ORG